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Public Health

Incoherent alcohol policy…. some thoughts

A recent piece by David Oliver shed some sense on what is most definitely an incoherent position on alcohol policy. The points raised are certainly valid.

There are other areas of incoherence worth highlighting and trying to rectify. Most visibly is the recent announcement of a strategic partnership with Drinkaware. The article skirted away (avoided) tackling this murky issue, assumedly on account of timing of publication.

There has been strong opposition to this move, most visibly the resignation of Sir Ian Gilmore from a key advisory committee. Oliver of PHE being increasingly compromised by cosying up to DrinkAware. Many have warned of the dangers of this partnership. This by Colin Angus is excellent. A WHO publication recently highlighted that 1.9% of corporate social responsibility activities were supported by evidence of effectiveness, and only 0.1% were consistent with “best buys” for prevention and control of NCDs. But such activities may have a public-relations advantage for the alcohol industry, as they will be seen by government and the public to be doing something, and thus the ‘heat’ taken out of pressure for upstream policies.

Treatment

It is widely accepted that we under invest in alcohol treatment interventions (across all levels) relative to the scale of risk and the need in our communities. It has been well documented that the ongoing cuts to the public health grant are a false economy. Local Government has zero manoeuvring room given the wider evisceration of local government funding over the last 6 or so years. Cuts have consequences. It is widely acknowledged this will simply set up future demand for NHS services and also will have a bearing on economic productivity of the workforce given the nature of epidemiology of alcohol harms. Did I say that primary care brief intervention is cost saving?

There are many skills developing issues we can address about scaling up brief interventions, asking wrong and closed questions, reluctance to challenge people.

The message and the culture

Getting the overall message right on alcohol is a huge issue that requires significant work. There are cultural issues here, and issues associated with risk communication.

On risk communication, the communication of the evidence base for alcohol and harm is frequently sited as confusing (red wine is good, red wine is bad, moderation is good, no drinking level is safe). The recent messy coverage of the Lancet story on “no safe level” erodes public trust in the evidence. There is a pressing need to move away from that space and be absolutely clear that we know that some (a lot) of people are harmed by alcohol. Prof Spiegelhalter sums this up most eloquently.

Arguably one of the reasons we under invest in treatment because we can because everything in health and wider society is geared towards making a joke of alcohol. There is highly irresponsible continuing practice from alcohol companies which is seemingly allowed on account of blind eye, tax receipts, and tolerance of marketing making jokes of alcoholism and excessive drinking. A beer called ‘delirium tremens brew’ is currently on the market.

Upstream approach to policy and intervention

As a society we have a strong push for a focus on downstream approaches, aided and abetted by industry and their lobbyists. Again the ferocious opposition of the Whisky Distillers against minimum unit price is testament to that.

In almost all circumstances, upstream interventions are always more potent impact wise, and more equitable. Witness the voracity of arguments against specific forms of upstream policy from commercial bodies who stand to loose from more powerful policies.

In order of preference, a public health approach to alcohol intervention would be focused on taxation or other price interventions, labelling, point of sales initiatives, marketing and in last place public awareness campaigns (innocuous at best, maybe net harmful maybe if they divert attention or bandwidth away from more powerful initiatives).

Of course there are many tricky evidence issues to deal with here. Marmot warned is that a strict biomedical approach to evidence will lead to a strong focus on drug treatment at the expense of policy on poverty. This requires careful handling.

DHSC or Treasury

The key incoherence is that alcohol policy is seen as a DHSC responsibility. Of course the NHS demand as a consequence of alcohol use are the domain of DHSC. given the epidemiology of harm, working age populations are also implicated, thus making it a societal and economic issue.

The Treasury is absent seemingly from any coherent conversation about advancing new alcohol policy, certainly publicly.

Those in the alcohol industry including advertisers, and they’re paid Associates and lobby groups always claim that the industry pays taxes and the tax receipt from alcohol sales always outweighs the harm that alcohol isn’t it good to the economy. I’ve never seen any coherent analysis that looks at benefit and harm from a whole societal perspective, usually the harm is an NHS perspective only I would also suggest that the evaluations of harm are undervalued and use model parameters most favourable to industry.

Where next.

The PHE 2016 evidence review provides a great deal of evidence based suggestions. Here are a few thoughts

Minimum Unit Pricing is mostly at the top of the list of policies. It has seemingly been shelved by government at the moment. I have yet to hear much or any NHS advocacy on Minimum Unit Price in England.

Similarly there is merit in a push for the inclusion of public health as a fifth objective in licensing decisions. This would give local government licensing committees significant additional power to flex local policies where there are specific issues.

Many local places are developing strong recovery models, something to be strongly supported and encouraged.

Some further investment and focus given to “new” areas would be welcome. Two specific examples – firstly scale up of systematic intervention around alcohol across the NHS. This has been done in some places in smoking using the London Clinical Senate Helping Smokers Quit model, the issues are similar in alcohol. The CQIN is helpful, but will likely be short lived, will focus on mechanisms and counting and not get into the culture / hearts and minds.

Secondly a focus on foetal alcohol syndrome as a significant and preventable cause of learning disability.

Thanks to Helen Phillips Jackson & Chris Gibbons

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